Sedative, hypnotic or anxiolytic dependence, in remission
ICD-10 F13.21 is a billable code used to indicate a diagnosis of sedative, hypnotic or anxiolytic dependence, in remission.
F13.21 refers to a condition characterized by a psychological and physical dependence on sedative, hypnotic, or anxiolytic substances, which are often prescribed for anxiety, sleep disorders, or muscle relaxation. In this context, 'in remission' indicates that the individual has not engaged in the use of these substances for a significant period, typically defined as at least one month, and is not currently experiencing withdrawal symptoms or cravings. The diagnosis of dependence is based on criteria such as tolerance, withdrawal, and continued use despite negative consequences. Treatment may involve behavioral therapies, support groups, and, in some cases, medication to manage underlying anxiety or sleep disorders. It is crucial for healthcare providers to monitor patients for potential relapse and to provide ongoing support to maintain remission. Accurate coding is essential for appropriate treatment planning and insurance reimbursement.
Detailed patient history, treatment plans, and progress notes are essential for accurate coding.
Patients transitioning from active substance use to recovery, those in outpatient therapy, and individuals requiring medication management.
Psychiatrists should document any co-occurring mental health disorders that may affect treatment and recovery.
Comprehensive assessments, including substance use history and treatment response, are critical.
Patients undergoing detoxification, those in rehabilitation programs, and individuals in aftercare.
Addiction specialists must ensure that all aspects of the patient's recovery journey are documented to support the diagnosis.
When a patient in remission is counseled on lifestyle changes to prevent relapse.
Document the counseling session details and patient response.
Counseling should be tailored to the patient's history of substance use.
'In remission' indicates that the patient has not used sedative, hypnotic, or anxiolytic substances for a significant period and is not experiencing withdrawal symptoms or cravings.
